The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SOUTHEASTERN REGIONAL MEDICAL CENTER 300 W 27 ST PO BOX 1408 LUMBERTON, NC 28359 Nov. 4, 2015
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy, medical record review and staff interviews, the nursing staff failed to monitor a patient receiving a blood transfusion per hospital policy for 4 of 4 patients receiving blood (Patient #1, #2, #3 and # 7).

The findings include:

Review of the hospital's policy, "Transfusion Therapy (Blood/Blood Components)", revised 05/2015, revealed, "A. Guidelines to Follow Prior to Actual Administration of Blood/Blood Components ... 3. Assess patient's status a. Prior to sending for blood take TPR (Temperature, Pulse, Respirations) and BP ( Blood Pressure) ... C. Guidelines for Documentation: 1. Documentation in patient record will be done in the Transfusion section of the Nursing Flowsheet Tab or paper record depending on unit, such as the Operating Room. Documentaion will include component or name of product. ... b. Time started c. Time completed (or discontinued). d. Vital Signs prior to sending for blood, 15 minutes post initiation, and every hour while infusing, and at the end of the transfusion..."

1. Closed medical record review of Patient #1 on 11/03/2015 revealed a [AGE] year old female admitted to the facility through the emergency department with a chief complaint of lower extremity pain on 09/30/2015. Record review revealed a physicians order on 09/30/2015 at 1709 to transfuse 2 units of PRBC's (Packed Red Blood Cells). Record review revealed first unit pre transfusion vital signs on 09/30/2015 at 1850. Record review revealed the first unit transfusion began at 1919 with vital signs taken at 1930 ( 11 minutes later), 2015 (45 minutes later) and 2140 ( 1 hour 25 minutes later) with the completion documented at 2119.

Interview on 11/04/2015 at 0845 with Nursing Administration revealed the nursing staff have been re-educated on the policy and procedure of Blood Administration and are aware of expectations. Interview confirmed the nursing staff did not follow hospital policy.

Interview on 11/04/2015 at 1445 with Nursing Director revealed audits of 10/2015 blood administration charts confirms that documentation compliance is an ongoing issue.

2. Closed medical record review on 11/03/2015 of Patient #3 revealed a [AGE] year old male admitted through the facility's emergency department on 10/23/15 for a chief complaint of dyspnea (shortness of breath) for 1 week. Record review revealed a physician's order on 10/24/2015 at 1123 to transfuse 2 units of PRBC's ( Packed Red Blood Cells). Record review revealed vital signs documented at 0835 with the first transfusion starting at 1230 (3 hours 55 minutes later) and vital signs documented at 1245 ( 15 minutes later), 1300 ( 15 minutes later) with the completion documented at 1400. Record review revealed no vital signs were documented at the completion of the blood transfusion. Record review revealed the second unit of RBC's (Packed Red Blood Cells) began infusing at 1545 with last vital signs documented at 1300 ( 2 hours 45 minutes prior). Record review revealed vital signs were documented at 1558 ( 13 minutes) after start of infusion. Record review revealed the infusion completed at 1747 and there was no documentation of hourly vitals signs or completion vital signs. Record review revealed vital signs documented at 2000 ( 3 hours 58 minutes later).

Interview on 11/04/2015 at 0845 with Nursing Administration revealed the nursing staff have been re-educated on the policy and procedure of Blood Administration and are aware of expectations. Interview confirmed the nursing staff did not follow hospital policy.

Interview on 11/04/2015 at 1445 with Nursing Director revealed audits of 10/2015 blood administration charts confirms that documentation compliance is an ongoing issue.





3. Closed medical record review on 11/03/2015 of Patient #2 revealed an [AGE] year old male admitted with a chief complaint of fever and a history of bone marrow cancer. Review of Patient #2's "Blood Transfusion Report" and "PRODUCT IDENTIFICATION TAG" reviewed a transfusion of one unit (roughly equivalent to one pint) of Red Blood Cells (RBCs) started on 10/05/2015 at 1645 and completed on 10/06/2015 at 2000. Further review of the record revealed vital signs were not documented for Patient #2 at the end of the transfusion of RBCs.

Interview on 11/04/2015 at 0845 with Nursing Administration revealed the nursing staff have been re-educated on the policy and procedure of Blood Administration and are aware of expectations. Interview confirmed the nursing staff did not follow hospital policy.

Interview on 11/04/2015 at 1445 with Nursing Director revealed audits of 10/2015 blood administration charts confirms that documentation compliance is an ongoing issue.

4. Closed medical record review on 11/03/2015 of Patient #7 revealed a [AGE] year old male who was admitted on [DATE] with a chief complaint of Severe Peripheral Vascular Disease (PVD - problem with poor blood flow that affects blood vessels outside of the heart and brain and gets worse over time) and Right Leg Pain. Further record review revealed Patient #7 developed lower gastrointestinal bleeding during his admission which required transfusion of blood products. Review of Patient #7's "Blood Transfusion Report" and "PRODUCT IDENTIFICATION TAG" revealed a transfusion of one unit of Red Blood Cells (RBCs) started on 09/15/2015 at 1857 and stopped on 09/18/2015 at 2052. Further review of the record revealed Patient #7's temperature was not documented at the end of the transfusion of RBCs. Continued review revealed Patient #7 received a transfusion of FFP (Fresh Frozen Plasma - the fluid portion of one unit of human blood) that started on 09/18/2015 at 2210 and stopped on 09/18/2015 at 2330. The record revealed Patient #7's temperature was not documented at the end of the FFP transfusion.

Interview on 11/04/2015 at 0845 with Nursing Administration revealed the nursing staff have been re-educated on the policy and procedure of Blood Administration and are aware of expectations. Interview confirmed the nursing staff did not follow hospital policy.

Interview on 11/04/2015 at 1445 with Nursing Director revealed audits of 10/2015 blood administration charts confirms that documentation compliance is an ongoing issue.

NC 293, NC 249